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Bazerbachi F, Haffar S, Garg SK, Lake JR. Extra-hepatic manifestations associated with hepatitis E virus infection: a comprehensive review of the literature. Gastroenterol Rep (Oxf) 2015; 4:1-15. [PMID: 26358655 PMCID: PMC4760069 DOI: 10.1093/gastro/gov042] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 07/09/2015] [Indexed: 02/07/2023] Open
Abstract
Background and aims: Hepatitis E virus (HEV) infection is a significant public health problem that afflicts almost 20 million individuals annually and causes acute liver injury in 3.5 million, with approximately 56 000 deaths. As with other viral hepatitides, extra-hepatic manifestations could represent an important aspect of this infection. The spectrum of these manifestations is still emerging. Acute pancreatitis and neurological, musculoskeletal, hematological, renal, and other immune-mediated manifestations have been described. The aim of this article is to comprehensively review the published literature of extra-hepatic manifestations associated with HEV infection. Data sources: We searched the PubMed database using the MeSH term “hepatitis E” and each of the extra-hepatic manifestations associated with HEV infection. No language or date restrictions were set in these searches. Searches retrieving articles with non-A, non-B hepatitis were excluded. Additional articles were identified through the reference lists of included articles. Results: Several extra-hepatic manifestations associated with HEV infection have been published. The temporal association between some extra-hepatic manifestations and HEV infection and the exclusion of other possible etiologies suggests that HEV infection could have caused some of them. According to the available data, HEV infection appears to be strongly associated with acute pancreatitis, neurological disorders (with primarily dominant peripheral nerve involvement, most commonly manifested as Guillain-Barré syndrome, followed by neuralgic amyotrophy), hematological diseases (hemolytic anemia due to glucose phosphate dehydrogenase deficiency, and severe thrombocytopenia), glomerulonephritis, and mixed cryoglobulinemia. More data are needed to clarify whether an association exists with musculoskeletal or other immune-mediated manifestations. Conclusions: HEV infection should be considered in patients with acute pancreatitis, Guillain-Barré syndrome, neuralgic amyotrophy, hemolytic anemia due to glucose phosphate dehydrogenase deficiency, severe thrombocytopenia, glomerulonephritis, and mixed cryoglobulinemia. Alternatively, signs and symptoms of these conditions should be sought in patients with acute or chronic HEV infection. More data are needed to confirm the role of HEV in other extra-hepatic disorders.
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Affiliation(s)
- Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Samir Haffar
- Department of Gastroenterology and Hepatology, University of Damascus, Damascus, Syrian Arab Republic
| | - Sushil K Garg
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
| | - John R Lake
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
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Anand A, Krishna GG, Sibley RK, Kambham N. Sjögren Syndrome and Cryoglobulinemic Glomerulonephritis. Am J Kidney Dis 2015; 66:532-5. [DOI: 10.1053/j.ajkd.2014.11.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/23/2014] [Indexed: 12/28/2022]
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Basile U, Gragnani L, Piluso A, Gulli F, Urraro T, Dell'Abate MT, Torti E, Stasi C, Monti M, Rapaccini GL, Zignego AL. Assessment of free light chains in HCV-positive patients with mixed cryoglobulinaemia vasculitis undergoing rituximab treatment. Liver Int 2015; 35:2100-7. [PMID: 25800731 DOI: 10.1111/liv.12829] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Mixed cryoglobulinaemia (MC) is an HCV-related lymphoproliferative disorder characterized by the presence of circulating immune complexes called cryoglobulins. Treatment with anti-CD20 monoclonal antibody rituximab is proved to be very useful, especially in patients ineligible to interferon-based antiviral therapy. Recently, free light chain (FLC) κ/λ ratio and FLC patterns were associated with MC. The aim of this study was to evaluate changes in FLC-κ, FCL-λ, FLC ratio following rituximab treatment in patients with HCV-related MC and to correlate FLC-κ, FCL-λ and FLC ratio values with therapy response. PATIENTS AND METHODS We retrospectively enrolled 46 patients with HCV infection (26 females, 20 males), including 10 patients without signs/symptoms of MC-related vasculitis, 36 with MC vasculitis. Clinical and biological data were recorded at baseline and 6 months after RTX treatment. Nephelometric measurement of serum FLCs was taken. RESULTS The mean serum FLC-κ level and FLC ratio were significantly higher in patients with MC, compared to HCV patients without MC and to blood donors. An abnormal FLC ratio at baseline correlated with the presence of cryoglobulins, C4 consumption, higher RF level and higher vasculitis rate. To evaluate the predictive value of FLCs, patients with MC were divided into two groups according to RTX therapy outcome (responders and no/partial responders). Abnormal baseline FLC ratio was significantly associated with no/partial response. CONCLUSIONS RTX treatment in HCV-related MC induces a reduction in FLC-κ and RF levels. Moreover, pretreatment FLC ratio, which can be easily assessed by a routine test, may be useful to predict response to this expensive treatment for patients with HCV-related MC ineligible to IFN-based therapy.
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Affiliation(s)
- Umberto Basile
- Department of Laboratory Medicine of the Catholic University of the Sacred Heart, Rome, Italy
| | - Laura Gragnani
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessia Piluso
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesca Gulli
- Department of Laboratory Medicine of the Catholic University of the Sacred Heart, Rome, Italy
| | - Teresa Urraro
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria T Dell'Abate
- Department of Laboratory Medicine of the Catholic University of the Sacred Heart, Rome, Italy
| | - Eleonora Torti
- Department of Laboratory Medicine of the Catholic University of the Sacred Heart, Rome, Italy
| | - Cristina Stasi
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Monica Monti
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Abstract
PURPOSE OF REVIEW Infections have been suggested to contribute to disease induction and reactivation in many of the idiopathic vasculitides. This review describes and evaluates the evidence that microbes are involved in the etiopathogenesis of these diseases. RECENT FINDINGS Large-vessel vasculitis has recently been associated with two specific bacteria. Mycobacterium tuberculosis is thought to have an inducing role in Takayasu arteritis and a Burkholderia bacterium might be involved in giant cell arteritis. Hepatitis B and C viruses have been linked to polyarteritis nodosa. In antineutrophil cytoplasmic autoantibody-associated vasculitis, and more specifically granulomatosis with polyangiitis (GPA), Staphylococcus aureus has been the focus of many studies. Chronic nasal carriage of S. aureus is related to endonasal activity and disease relapses in GPA patients. Moreover, antibacterial treatment is known to reduce the risk for disease relapses. If and how pathogens trigger vasculitis is still unclear, but several potential mechanisms have been suggested and are briefly reviewed here. SUMMARY Although many observations suggest a link between infections and the development of vasculitis, no direct proof exists. Transcriptomic and proteomic studies of the pathogens involved could aid in identifying specific or common traits of pathogens that are relevant for the development and reactivation of vasculitis.
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Ramos-Casals M, Brito-Zerón P, Seror R, Bootsma H, Bowman SJ, Dörner T, Gottenberg JE, Mariette X, Theander E, Bombardieri S, De Vita S, Mandl T, Ng WF, Kruize A, Tzioufas A, Vitali C. Characterization of systemic disease in primary Sjögren's syndrome: EULAR-SS Task Force recommendations for articular, cutaneous, pulmonary and renal involvements. Rheumatology (Oxford) 2015; 54:2230-8. [PMID: 26231345 DOI: 10.1093/rheumatology/kev200] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To reach a European consensus on the definition and characterization of the main organ-specific extraglandular manifestations in primary SS. METHODS The EULAR-SS Task Force Group steering committee agreed to approach SS-related systemic involvement according to the EULAR SS Disease Activity Index (ESSDAI) classification and proposed the preparation of four separate manuscripts: articular, cutaneous, pulmonary and renal ESSDAI involvement; muscular, peripheral nervous system, CNS and haematological ESSDAI involvement; organs not included in the ESSDAI classification; and lymphoproliferative disease. Currently available evidence was obtained by a systematic literature review focused on SS-related systemic features. RESULTS The following information was summarized for articular, cutaneous, pulmonary and renal involvement: a clear, consensual definition of the clinical feature, a brief epidemiological description including an estimate of the prevalence reported in the main clinical series and a brief list of the key clinical and diagnostic features that could help physicians clearly identify these features. Unfortunately we found that the body of evidence relied predominantly on information retrieved from individual cases, and the scientific information provided was heterogeneous. The analysis of types of involvement was biased due to the unbalanced reporting of severe cases over non-severe cases, although the main sources of bias were the heterogeneous definitions of organ involvement (or even the lack of definition in some studies) and the heterogeneous diagnostic approach used in studies to investigate involvment of each organ. CONCLUSION The proposals included in this article are a first step to developing an optimal diagnostic approach to systemic involvement in primary SS and may pave the way for further development of evidence-based diagnostic and therapeutic guidelines.
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Affiliation(s)
- Manuel Ramos-Casals
- Sjögren Syndrome Research Group (AGAUR), Laboratory of Autoimmune Diseases Josep Font, IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain,
| | - Pilar Brito-Zerón
- Sjögren Syndrome Research Group (AGAUR), Laboratory of Autoimmune Diseases Josep Font, IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
| | - Raphaèle Seror
- Department of Rheumatology, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hopitaux de Paris, Le Kremlin Bicêtre, Université Paris-Sud 11, UMR 1184, Le Kremlin Bicêtre, Paris, France
| | - Hendrika Bootsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Simon J Bowman
- Rheumatology Department, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Thomas Dörner
- Rheumatology Department, Charité, University Hospital, Berlin, Germany
| | - Jacques-Eric Gottenberg
- Department of Rheumatology, EA 4438, Strasbourg University Hospital, Université de Strasbourg, Strasbourg, France
| | - Xavier Mariette
- Department of Rheumatology, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hopitaux de Paris, Le Kremlin Bicêtre, Université Paris-Sud 11, UMR 1184, Le Kremlin Bicêtre, Paris, France
| | - Elke Theander
- Department of Rheumatology, Skane University Hospital Malmö, Lund University, Sweden
| | | | - Salvatore De Vita
- Clinic of Rheumatology, Department of Medical and Biological Sciences, University Hospital Santa Maria della Misericordia, Udine, Italy
| | - Thomas Mandl
- Department of Rheumatology, Skane University Hospital Malmö, Lund University, Sweden
| | - Wan-Fai Ng
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Aike Kruize
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Athanasios Tzioufas
- Department of Pathophysiology, School of Medicine, University of Athens, Greece and
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Damoiseaux J, Cohen Tervaert JW. Diagnostics and treatment of cryoglobulinaemia: it takes two to tango. Clin Rev Allergy Immunol 2015; 47:299-310. [PMID: 24068540 DOI: 10.1007/s12016-013-8390-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Cryoglobulins are immunoglobulins that reversibly precipitate in the cold. They come in different flavours and, as such, are differentially associated with lymphoproliferative diseases (type I), or systemic autoimmune diseases, and/or infectious diseases (type II/III). The clinical manifestations of cryoglobulinaemia result from either hyper-viscosity or small vessel vasculitis. Hepatitis C virus (HCV) is a well-known factor in the aetiology of cryoglobulinaemia, but substantial geographical differences exist in the association between cryoglobulins and HCV. In the absence of any underlying disease, cryoglobulinaemia is referred to as 'idiopathic' or 'essential'. Detection of cryoglobulins in the laboratory is hampered by several pitfalls, in particular in the pre-analytical stage as well as in the quantification. In addition, our personal experience reveals that the detection of rheumatoid factor, most often present in high concentrations in patients with mixed cryoglobulinaemia, relies on the choice of the test system. Hence, interpretation of the laboratory results in relation to the clinical manifestations requires a partnership between the clinician and the laboratory specialist in order to make a correct diagnosis. Treatment options are primarily directed by identification of underlying diseases, i.e. infections or systemic autoimmune diseases. Idiopathic cryoglobulinaemia is treated with corticosteroids and immunosuppression, or B cell depleting anti-CD20 biologicals. In this overview, the recent literature on current laboratory and clinical practice of cryoglobulinaemia is discussed from a personal perspective.
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Affiliation(s)
- Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands,
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Renal disease presenting as acute kidney injury: the diagnostic conundrum on the intensive care unit. Curr Opin Crit Care 2015; 20:606-12. [PMID: 25340380 DOI: 10.1097/mcc.0000000000000155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is commonplace in most ICUs. In many cases the cause is believed to be multifactorial with sepsis being a major component. However, occasionally intrinsic renal disease will present to the ICU and as such critical care practitioners should be aware of this possibility and the ways in which such conditions may present. RECENT FINDINGS Although a relatively rare occurrence the treatment for patients with intrinsic renal disease, particularly those who present as part of a vasculitic process, differs considerably from usual organ support employed on intensive care. Recent studies indicate that the outlook for these patients is poor particularly when the diagnosis is delayed. The use of serological investigations as well as other diagnostic techniques are discussed. SUMMARY Not all AKI as described by changes in creatinine and urine output which presents or develops on the ICU is the same. AKI is a syndrome which encompasses many conditions and as such is nondiagnostic. Clinicians, when faced with AKI should satisfy themselves as to the likely cause of the AKI.
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Kong F, Zhang W, Feng B, Zhang H, Rao H, Wang J, Cong X, Wei L. Abnormal CD4 + T helper (Th) 1 cells and activated memory B cells are associated with type III asymptomatic mixed cryoglobulinemia in HCV infection. Virol J 2015; 12:100. [PMID: 26129991 PMCID: PMC4501109 DOI: 10.1186/s12985-015-0324-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 06/12/2015] [Indexed: 12/23/2022] Open
Abstract
Background Mixed cryoglobulinemia (MC) in hepatitis C virus (HCV) infection is associated with abnormal immune responses mediated by T cells and B cells, while the relationships of different subsets of CD4 + T helper (Th) cells, B cells and associated cytokines with type III asymptomatic MC in HCV infection are poorly understood. Methods Fifty-four chronic hepatitis C (CHC) patients and 23 healthy controls (HCs) were enrolled in the study. Serum cryoglobulins were detected by cryoprecipitation. The types of cryoglobulin were determined by western blot. The phenotypes and frequencies of Th cell and B cell subsets were detected by flow cytometric analysis. The cytokines IFN-γ, IL-4, IL-17, IL-21, IL-22, and TGF-β were measured by enzyme-linked immunosorbent assay. Results Twenty-six CHC patients were detected with type III asymptomatic MC. The frequencies of Th2, Th17, follicular helper T (Tfh cells), Th22, and tissue-like B cells were significantly higher in CHC patients compared to HCs, while these cell subsets were not significantly different between CHC patients and HCV-related MC patients. The frequencies of Th1 and activated memory B cells increased in HCV-related MC patients compared to HCs, although the difference between the two cell subsets in CHC patients and HCs was not significant. The frequency of regulatory T cells (Treg cells) was higher in CHC patients than in HCV-related MC patients and HCs. Higher expressions of serum IFN-γ, IL-17, IL-21, and IL-22 were observed in CHC patients than in HCs, but the differences were not significantly different in CHC patients and HCV-related MC patients. The frequency of Th1 cells was associated with activated memory B cells in HCV-related MC patients, and the frequency of Th1 cells and activated memory B cells was closely related to HCV RNA in HCV-related MC patients. Conclusions The increased frequencies of Th17 cells, Tfh cells, Th22 cells, Treg cells, cytokines IL-17, IL-21, IL-22, and tissue-like B cells, were related to HCV infection but not type III asymptomatic MC. Higher frequencies of Th1 cells and activated memory B cells were associated with type III asymptomatic MC in HCV infection.
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Affiliation(s)
- Fanyun Kong
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, No.11 Xizhimen South Street, Beijing, 100044, China. .,Department of Pathogenic biology and Laboratory of Infection and Immunology, Xuzhou Medical College, 84 West Huaihai Road, Xuzhou, 221002, Jiangsu Province, China.
| | - Wei Zhang
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, No.11 Xizhimen South Street, Beijing, 100044, China.
| | - Bo Feng
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, No.11 Xizhimen South Street, Beijing, 100044, China.
| | - Henghui Zhang
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, No.11 Xizhimen South Street, Beijing, 100044, China.
| | - Huiying Rao
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, No.11 Xizhimen South Street, Beijing, 100044, China.
| | - Jianghua Wang
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, No.11 Xizhimen South Street, Beijing, 100044, China.
| | - Xu Cong
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, No.11 Xizhimen South Street, Beijing, 100044, China.
| | - Lai Wei
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, No.11 Xizhimen South Street, Beijing, 100044, China.
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Dedania B, Wu GY. Dermatologic Extrahepatic Manifestations of Hepatitis C. J Clin Transl Hepatol 2015; 3:127-33. [PMID: 26357639 PMCID: PMC4548357 DOI: 10.14218/jcth.2015.00010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/24/2015] [Accepted: 04/26/2015] [Indexed: 12/11/2022] Open
Abstract
Hepatitis C virus (HCV) affects millions of people worldwide, and an estimated 3.2 million people in the United States. HCV is a hepatotropic and lymphotropic virus that causes not only liver disease, but also a significant number of extrahepatic manifestations (EHMs). Up to 74% of patients affected by HCV will have HCV-related EHMs of some severity in their lifetime. The EHMs vary from simple cutaneous palpable purpura to complex lymphoproliferative disorders, including lymphomas and immune-complex deposit diseases causing local and/or systemic complications. Mixed cryoglobulinemia (MC) is manifested by multiple systemic organ involvement, mainly skin, kidney, peripheral nerves, and salivary glands, and less frequently causes widespread vasculitis and malignant lymphoma. MC affects up to 3% of HCV-infected patients with cryoglobulinemia of clinical significance, i.e. >6%. Severe disease requires immunosuppressive or plasma exchange therapy. HCV prevalence in the United States in patients with porphyria cutanea tarda (PCT) was reported to be 66%, much higher than that in general population. Therefore, all patients with PCT should be screened for HCV. The skin rash of PCT varies from large blisters to small vesicles and/or milia on the hands. Skin manifestations due to PCT usually respond to anti-HCV treatment together with reducing skin sun exposure, avoiding triggers, having routine phlebotomy (especially for people with chronic iron overload states), and using chloroquine. Lichen planus (LP), which typically affects both the skin and oral mucosa is a chronic inflammatory disease of squamous cell origin affecting about 1% of the worldwide population. The prevalence of HCV in patients with LP varies based on geographic location. We review here the basic pathophysiology, clinical features, and management of dermatologic manifestations of HCV.
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Affiliation(s)
- Bhavtosh Dedania
- Correspondence to: Bhavtosh Dedania, Department of Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030, USA. Tel: +1‐267‐475‐0383, Fax: +1‐860‐679‐4613, E‐mail:
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Abstract
PURPOSE OF REVIEW This article discusses the clinical features, pathophysiology, and management of primary and secondary acquired immune axonal neuropathies. RECENT FINDINGS Although there are many collagen vascular disorders associated with vasculitic neuropathy, a quarter of cases have been described to be due to nonsystemic vasculitis of the peripheral nervous system. Enhanced surveillance and aggressive treatment of conditions such as cryoglobulin-related vasculitic neuropathy with cyclophosphamide, rituximab, and alfa interferons has led to improved morbidity and mortality, however, many cases of immune axonal acquired neuropathy are still associated with poor outcomes. Acute motor axonal neuropathy (AMAN) and acute motor sensory axonal neuropathy (AMSAN) are well-characterized variants of Guillain-Barré syndrome. SUMMARY Characterizing the clinical and electrophysiologic phenotype can help diagnose conditions such as nonsystemic vasculitic neuropathy, AMAN, AMSAN, and immune small fiber neuropathy, while careful evaluation of systemic features is key to identifying secondary immune axonal neuropathies such as vasculitic neuropathy related to collagen vascular disease. Additional research is needed to determine the exact immune pathogenesis and optimized treatment regimens for all acquired immune axonal neuropathies.
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Vasculopatía oclusiva por crioglobulinemia tipo I en mieloma múltiple IgG lambda. Rev Clin Esp 2015; 215:e39-42. [DOI: 10.1016/j.rce.2015.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 01/25/2015] [Indexed: 11/20/2022]
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[Prognosis and therapy of inflammatory rheumatic diseases : Impact of renal manifestations]. Z Rheumatol 2015; 74:310-21. [PMID: 25962452 DOI: 10.1007/s00393-014-1479-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inflammatory rheumatic diseases and their treatment cause various renal manifestations requiring modification of treatment. OBJECTIVES Discussion of renal manifestations in selected rheumatic diseases, including their impact on general prognosis and therapy. MATERIALS AND METHODS Basic literature and expert opinions are analyzed and discussed. RESULTS Inflammatory rheumatic diseases and their treatment cause various renal manifestations, including glomerular, tubular, interstitial, and vascular damage. The type of damage determines both, associated clinical symptoms (i.e. hematuria, proteinuria, loss of kidney function) and the renal and overall survival as will be discussed here for rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjögrens syndrome, cryoglobulinemia and ANCA-associated vasculitis. CONCLUSION Renal manifestations are generally indicators of high disease activity and usually require more intensive treatment of the underlying rheumatic disease. Early and rigorous treatment, which has to be adapted to renal function, is capable of improving renal and overall survival in many of the affected patients.
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Retamozo S, Brito-Zerón P, Ramos-Casals M. [Treatment of cryoglobulinemic vasculitis associated with hepatitis C virus infection]. Med Clin (Barc) 2015; 144:410-7. [PMID: 24787686 DOI: 10.1016/j.medcli.2014.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 02/13/2014] [Accepted: 02/27/2014] [Indexed: 10/25/2022]
Abstract
Cryoglobulinemia is a heterogeneous systemic autoimmune disease with a wide variety of causes, symptoms and outcomes, and different etiopathogenic pathways involved in the vasculitic organ damage. The discovery of the hepatitis C virus (HCV) in 1989 changed radically the focus of research of the so-called "essential" cryoglobulinemia. Cryoglobulins can be detected in 25-30% of patients with HCV, overwhelmingly representing mixed cryoglobulins. However, only 10-15% of patients present with cryoglobulinemic vasculitis, with a broad spectrum of symptoms including mild or life-threatening manifestations. Consequently, not all patients can be uniformly treated. The key therapeutic points in HCV+ patients with cryoglobulinemic vasculitis cover different aspects. The first is to treat the underlying cause of cryoglobulinemia whenever possible, hence the use of antiviral therapies must always be considered in these patients. An individualized diagnostic approach to assess the number of organs involved and the severity of organ involvement is also essential in the therapeutic planning. This complex clinical scenario leads to an equally complex therapeutic scenario. There are three main treatment strategies for HCV-associated cryoglobulinemic vasculitis: conventional immunosuppression, antiviral treatment and biological therapies. The most recent studies are suggesting a change from the classical therapeutic approach (monotherapeutic regimens) to combination/sequential regimens, including treatments targeting the virus and those directed against the induced autoimmune disease, with the aim of blocking the various etiopathogenic pathways involved.
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Affiliation(s)
- Soledad Retamozo
- Laboratorio de Enfermedades Autoinmunes Josep Font, Centro de Investigación Biomédica CELLEX-Institut d'Investigacions Biomèdiques August Pi i Sunyer (CELLEX-IDIBAPS), Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia (ICMiD), Hospital Clínic, Barcelona. España
| | - Pilar Brito-Zerón
- Laboratorio de Enfermedades Autoinmunes Josep Font, Centro de Investigación Biomédica CELLEX-Institut d'Investigacions Biomèdiques August Pi i Sunyer (CELLEX-IDIBAPS), Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia (ICMiD), Hospital Clínic, Barcelona. España
| | - Manuel Ramos-Casals
- Laboratorio de Enfermedades Autoinmunes Josep Font, Centro de Investigación Biomédica CELLEX-Institut d'Investigacions Biomèdiques August Pi i Sunyer (CELLEX-IDIBAPS), Servicio de Enfermedades Autoinmunes, Institut Clínic de Medicina i Dermatologia (ICMiD), Hospital Clínic, Barcelona. España.
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Silva de Souza AW. Autoantibodies in systemic vasculitis. Front Immunol 2015; 6:184. [PMID: 25954277 PMCID: PMC4406058 DOI: 10.3389/fimmu.2015.00184] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/03/2015] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alexandre Wagner Silva de Souza
- Rheumatology Division, Department of Internal Medicine, Universidade Federal de São Paulo-Escola Paulista de Medicina , São Paulo , Brazil
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267
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Blaes F. Diagnosis and therapeutic options for peripheral vasculitic neuropathy. Ther Adv Musculoskelet Dis 2015; 7:45-55. [PMID: 25829955 PMCID: PMC4357592 DOI: 10.1177/1759720x14566617] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Vasculitis can affect the peripheral nervous system alone (nonsystemic vasculitic neuropathy) or can be a part of primary or secondary systemic vasculitis. In cases of pre-existing systemic vasculitis, the diagnosis can easily be made, whereas suspected vasculitic neuropathy as initial or only manifestation of vasculitis requires careful clinical, neurophysiological, laboratory and histopathological workout. The typical clinical syndrome is mononeuropathia multiplex or asymmetric neuropathy, but distal-symmetric neuropathy can frequently be seen. Standard treatments include steroids, azathioprine, methotrexate and cyclophosphamide. More recently the B-cell antibody rituximab and intravenous immunoglobulins have shown to be effective in some vasculitic neuropathy types.
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Affiliation(s)
- Franz Blaes
- Department of Neurology, KKH Gummersbach, Wilhelm-Breckow-Allee 20, 51643 Gummersbach, Germany
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268
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[Hyperviscosity syndrome]. Rev Med Interne 2015; 36:588-95. [PMID: 25778852 DOI: 10.1016/j.revmed.2015.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 01/08/2015] [Accepted: 02/07/2015] [Indexed: 12/12/2022]
Abstract
Hyperviscosity syndrome is a life-threatening complication. Clinical manifestations include neurological impairment, visual disturbance and bleeding. Measurement of plasma or serum viscosity by a viscometer assesses the diagnosis. Funduscopic examination is a key exam because abnormalities are well-correlated with abnormal plasma viscosity. Etiologies are various but symptomatic hyperviscosity is more common in Waldenström's macroglobulinemia and multiple myeloma. Prompt treatment is needed: treatment of the underlying disease should be considered, but generally not sufficient. Symptomatic measures aim to not exacerbate blood viscosity while urgent plasmapheresis effectively reduces the paraprotein concentration and relieves symptoms.
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269
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Georgiadou SP, Stefos A, Spanakos G, Skrimpas S, Makaritsis K, Sipsas NV, Dalekos GN. Current clinical, laboratory, and treatment outcome characteristics of visceral leishmaniasis: results from a seven-year retrospective study in Greece. Int J Infect Dis 2015; 34:46-50. [PMID: 25743761 DOI: 10.1016/j.ijid.2015.02.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Visceral leishmaniasis (VL) is re-emerging in endemic areas. The epidemiological, clinical, laboratory, and treatment outcome characteristics in a large cohort of VL patients is described herein. METHODS The cases of 67 VL patients (57% male, mean age 56 years) treated in two Greek hospitals over the last 7 years were identified and evaluated retrospectively. RESULTS Forty-six percent of patients reported contact with animals. Seventeen patients (25%) were immunocompromised, and 22% were co-infected with another pathogen. Sixty-four percent of patients had fever, 57% had weakness, 37% had sweats, 21% had weight loss, and 13% had a dry cough, while 6% developed haemophagocytic syndrome. The median duration of symptoms was 28 days. Fifty-eight percent of patients had splenomegaly, 49% had hepatomegaly, and 36% had lymphadenopathy. The diagnosis was established by positive PCR in peripheral blood (73%) and/or bone marrow specimens (34%). Sixty-one patients (91%) received liposomal amphotericin (L-AMB). Six patients (10%) did not respond or relapsed but were eventually cured after a second cycle of L-AMB. During a 6-month follow-up, the overall mortality was 9%, although none of these deaths was attributed to VL. CONCLUSIONS VL is still a common disease in endemic areas, affecting immunocompetent and immunocompromised patients. Its diagnosis is challenging, and molecular techniques are valuable and helpful tools to achieve this. Treatment with L-AMB is safe and very effective.
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Affiliation(s)
- Sarah P Georgiadou
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Biopolis, 41110, Larissa, Greece
| | - Aggelos Stefos
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Biopolis, 41110, Larissa, Greece
| | - Gregory Spanakos
- Department of Parasitology, Entomology and Tropical Diseases, National School of Public Health, Athens, Greece
| | - Stergios Skrimpas
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Biopolis, 41110, Larissa, Greece
| | - Konstantinos Makaritsis
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Biopolis, 41110, Larissa, Greece
| | - Nikolaos V Sipsas
- Department of Pathophysiology, Laikon General Hospital and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Biopolis, 41110, Larissa, Greece.
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270
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Abstract
Monoclonal gammopathy is produced by neoplastic or non-neoplastic expansion of a clone of plasma cells or B lymphocytes. Monoclonal gammopathy of unknown significance is characterized by low levels of the monoclonal protein and a relatively small population of clonal lymphocytes or plasma cells in the bone marrow. In these cases, the patient is asymptomatic with no evidence of overt myeloma or lymphoma. The abnormal serum protein may be present as a complete immunoglobulin molecule or may consist of ≥1 of its components such as light chains or heavy chains. These proteins may cause a variety of diseases in various tissues and organs, of which the kidney appears to be the most vulnerable. Renal involvement in monoclonal gammopathy may occur as part of a generalized disease such as amyloidosis, immunoglobulin deposition disease, and cryoglobulinemia. In addition, there may be evidence of kidney damage by processes which are renal specific. These include light chain proximal tubulopathy, light chain cast nephropathy, and a variety of glomerulopathies encompassing a wide spectrum of disease patterns.
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271
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Rogalska-Płońska M, Lapinski TW, Grzeszczuk A, Parfieniuk-Kowerda A, Flisiak R. Influence of HCV and HIV on development of cryoglobulinemia. Viral Immunol 2015; 28:145-52. [PMID: 25723551 DOI: 10.1089/vim.2014.0114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Cryoglobulinemic syndrome refers to a systemic inflammatory process that involves small and medium-sized vessels accompanied by multi-organ damage. The aim of the present study was to determine the incidence of cryoglobulinemia among patients infected with human immunodeficiency virus (HIV), hepatitis C virus (HCV) and HCV/HIV co-infection, as well as evaluation of cryoglobulinemia type. The association was evaluated between cryoglobulinemia and clinical symptoms, selected biochemical measures of liver and kidney function, virologic measures, as well as histopathological changes in the liver. One hundred and forty-one patients were enrolled (59 HCV mono-infected, 48 HIV mono-infected, and 34 HCV/HIV co-infected). Cryoglobulinemia was nearly five times less frequent among HIV mono-infected patients (10%) than HCV mono-infected (53%) and HCV/HIV co-infected patients (59%). Cryoglobulinemia was more frequent in patients infected with genotype 1 HCV than genotype 3 (63% vs. 46%, p=0.12). There was a lower incidence of cryoglobulinemia in HIV mono-infected patients treated with antiretroviral drugs (p=0.04). Cryoglobulinemia correlated with ALT activity (p=0.01) and HIV viral load (p<0.001). Symptoms were significantly more frequent among cryoglobulinemic patients than those without cryoglobulinemia (38% vs. 9%, p<0.001). The most common symptoms related to cryoglobulinemia, regardless of cryoglobulinemia type, were fatigue (38%), arthralgia (20%), polineuropathy (18%), and skin lesions (14%). In conclusion, HCV mono-infection and HCV/HIV co-infection, regardless of HCV genotype, are potent stimulators of cryoglobulinemia, with its symptomatic form occurring in about 40% of cases. Effective antiretroviral therapy seems to be protective against cryoglobulinemia development in HIV mono-infected patients.
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272
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Bunchorntavakul C, Maneerattanaporn M, Chavalitdhamrong D. Management of patients with hepatitis C infection and renal disease. World J Hepatol 2015; 7:213-25. [PMID: 25729476 PMCID: PMC4342603 DOI: 10.4254/wjh.v7.i2.213] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 11/10/2014] [Accepted: 11/17/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) infection in patients with end-stage renal disease (ESRD) is associated with more rapid liver disease progression and reduced renal graft and patients' survival following kidney transplantation. Evaluations and management of HCV in patients with renal disease are challenging. The pharmacokinetics of interferons (IFN), ribavirin (RBV) and some direct acting antiviral (DAA), such as sofosbuvir, are altered in patients with ESRD. With dose adjustment and careful monitoring, treatment of HCV in patients with ESRD can be associated with sustained virological response (SVR) rates nearly comparable to that of patients with normal renal function. DAA-based regimens, especially the IFN-free and RBV-free regimens, are theoretically preferred for patients with ESRD and KT in order to increase SVR rates and to reduce treatment side effects. However, based on the data for pharmacokinetics, dosing safety and efficacy of DAA for patients with severe renal impairment are lacking. This review will be focused on the evaluations, available pharmacologic data, and management of HCV in patients with severe renal impairment, patients who underwent KT, and those who suffered from HCV-related renal disease, according to the available treatment options, including DAA.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Chalermrat Bunchorntavakul, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Monthira Maneerattanaporn
- Chalermrat Bunchorntavakul, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Disaya Chavalitdhamrong
- Chalermrat Bunchorntavakul, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
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273
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Ghetie D, Mehraban N, Sibley CH. Cold Hard Facts of Cryoglobulinemia. Rheum Dis Clin North Am 2015; 41:93-108, viii-ix. [DOI: 10.1016/j.rdc.2014.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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274
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Comparison between the traditional and a rapid screening test for cryoimmunoglobulins detection. BIOMED RESEARCH INTERNATIONAL 2015; 2015:783063. [PMID: 25692146 PMCID: PMC4321088 DOI: 10.1155/2015/783063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 01/03/2015] [Indexed: 12/31/2022]
Abstract
OBJECTIVES A new rapid, automatic, and sensitive screening test useful to detect cryoglobulins in serum samples is proposed. DESIGN AND METHODS The increase of turbidity during the cryoglobulin aggregation was monitored spectrophotometrically in sera from 400 patients with clinical evidence of cryoglobulinemia related disorders and 100 controls. Results were correlated to those obtained by the traditional method. RESULTS Kinetics of the aggregation curves were described by their maximum turbidity increase, lag time, and slope. Despite a partial correspondence between the traditional and the rapid test, patients with symptomatic cryoglobulinemia showed turbidity values significantly higher than the determined cutoff. Moreover, a functional classification of cryoglobulins is proposed. CONCLUSIONS Due to its high reproducibility, operator independence, low cost, and results obtained within 2 hours, the rapid test can be used as a "real time" monitoring of cryoglobulinemia related diseases and for the evaluation of plasmapheresis efficacy.
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275
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Sim BWC, Koo RM, Hawkins C, Bowden F, Watson A. Granulicatella adiacens subacute bacterial endocarditis as the underlying cause of type II mixed cryoglobulinaemia. BMJ Case Rep 2015; 2015:bcr-2014-206091. [PMID: 25568266 DOI: 10.1136/bcr-2014-206091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 57-year-old man with type II mixed cryoglobulinaemia presented to the emergency department with a history of worsening lethargy, malaise and non-drenching night sweats in a relapsing-remitting pattern. He was diagnosed with type II mixed cryoglobulinaemia 7 months ago following episodes of fever, night sweats, lethargy and malaise associated with a non-blanching, purpuric, raised erythematous rash that responded partially to immunosuppressive therapy and short courses of oral antibiotics. A single blood culture then yielded Granulicatella adiacens which was reported as a possible contaminant and therefore, not pursued. Despite numerous other investigations, the underlying cause of his type II cryoglobulinaemia remained undetermined. On his current presentation, the physical examination revealed signs of infective endocarditis. Two further blood cultures grew G. adiacens. The diagnosis of infective endocarditis was established on a transoesophageal echocardiography, and the subsequent antibiotic and surgical therapy resulted in complete remission of his type II mixed cryoglobulinaemia.
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Affiliation(s)
- Benjamin W C Sim
- Infectious Diseases Unit, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Ray Mun Koo
- Infectious Diseases Unit, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Carolyn Hawkins
- Department of Immunology, The Canberra Hospital, Canberra, Australian Capital Territory, Australia Australian National University (ANU) Medical School, Canberra, Australian Capital Territory, Australia
| | - Francis Bowden
- Infectious Diseases Unit, The Canberra Hospital, Canberra, Australian Capital Territory, Australia Australian National University (ANU) Medical School, Canberra, Australian Capital Territory, Australia
| | - Ashley Watson
- Infectious Diseases Unit, The Canberra Hospital, Canberra, Australian Capital Territory, Australia Australian National University (ANU) Medical School, Canberra, Australian Capital Territory, Australia
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276
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Rossa AD, Tavoni A, Bombardieri S. Cryoglobulinemia. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00163-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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277
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Mariotte É. Échanges plasmatiques : indications en réanimation. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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278
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Vassilopoulos D, Calabrese LH. Rheumatologic aspects of viral infections. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00110-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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279
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Saadoun D, Resche Rigon M, Pol S, Thibault V, Blanc F, Pialoux G, Karras A, Bazin-Kara D, Cazorla C, Vittecoq D, Musset L, Peltier J, Decaux O, Ziza JM, Lambotte O, Cacoub P. PegIFNα/ribavirin/protease inhibitor combination in severe hepatitis C virus-associated mixed cryoglobulinemia vasculitis. J Hepatol 2015; 62:24-30. [PMID: 25135864 DOI: 10.1016/j.jhep.2014.08.015] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 07/15/2014] [Accepted: 08/09/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS The aim of this study was to analyse the safety and efficacy of the PegIFNα/ribavirin/protease inhibitor combination in severe and/or refractory hepatitis C virus (HCV)-mixed cryoglobulinemia (MC) vasculitis. METHODS This prospective cohort study included 30 patients (median age 59 years [53-66] and 57% of women) with HCV-MC vasculitis. PegIFNα/ribavirin (for 48 weeks) was associated with telaprevir (375 mg three times daily, for 12 weeks, [n = 17]) or boceprevir (800 mg three times daily, for 44 weeks, (n = 13]). RESULTS Twenty three patients (76.7%) were non-responders to previous antiviral therapy. At week 72, twenty patients (66.7%) were complete clinical and sustained virological responders. The cryoglobulin level decreased from 0.45 to 0 g/L (p<0.0001) and the C4 level increased from 0.09 to 0.14 g/L (p = 0.017). Complete clinical responders had a higher frequency of purpura (16/20 [80%] vs. 4/10 [40%], p = 0.045), and a trend towards lower frequency of neuropathy (9/20 (45%) vs. 8/10 [80%], p = 0.12) compared with partial responders. Serious adverse events occurred in 14 patients (46.6%) during the 72 weeks of follow-up. Twenty eight patients (93.3%) received erythropoietin, 14 (46.6%) had red blood cell transfusion and 2 (6.6%) received granulocyte stimulating agent. The baseline factors associated with serious adverse events included liver fibrosis (p = 0.045) and a low platelet count (p = 0.021). CONCLUSIONS The PegIFNα/ribavirin/protease inhibitor combination is highly effective in severe and/or refractory HCV-MC at the cost of frequent side effects. Baseline platelet count and liver fibrosis are useful in guiding treatment decisions.
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Affiliation(s)
- David Saadoun
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital Pitié-Salpétrière, DHU I2B, Immunopathology, Inflammation, Biotherapy, Paris, France; Université Pierre et Marie Curie, Paris VI, UMR CNRS 7211, INSERM U959, Hôpital Pitié-Salpétrière, Paris, France.
| | | | - Stanislas Pol
- Department of Hepatology, Hôpital Necker, Paris, France
| | - Vincent Thibault
- Department of Virology, Hôpital Pitié-Salpétrière, Paris, France
| | - François Blanc
- Department of Internal Medicine, Hôpital Lapeyronie, Montpellier, France
| | - Gilles Pialoux
- Department of Infectious Diseases, Hôpital Tenon, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen George Pompidou, Paris, France
| | | | - Cécile Cazorla
- Department of Internal Medicine, Centre Hospitalier de Nouvelle Calédonie, Nouméa, France
| | - Daniel Vittecoq
- Department of Infectious Diseases, Hôpital Paul Brousse, Villejuif, France
| | - Lucile Musset
- Laboratory of Immunochemistry, Hôpital Pitié-Salpétrière, Paris, France
| | - Julie Peltier
- Department of Nephrology, Hôpital Tenon, Paris, France
| | - Olivier Decaux
- Department of Internal Medicine, Hôpital Sud, Rennes, France
| | - Jean-Marc Ziza
- Department of Internal Medicine, Hôpital Croix Saint Simon, Paris, France
| | - Olivier Lambotte
- Department of Internal Medicine, Hôpital Bicêtre, Kremlin Bicêtre, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital Pitié-Salpétrière, DHU I2B, Immunopathology, Inflammation, Biotherapy, Paris, France; Université Pierre et Marie Curie, Paris VI, UMR CNRS 7211, INSERM U959, Hôpital Pitié-Salpétrière, Paris, France.
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280
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Anti-nuclear antibody detection in cryoprecipitates: distinctive patterns in hepatitis C virus-infected patients. Dig Liver Dis 2015; 47:50-6. [PMID: 25445409 DOI: 10.1016/j.dld.2014.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/02/2014] [Accepted: 09/13/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anti-nuclear antibodies are immunoglobulins directed against nuclear antigens. They are associated with many autoimmune disorders, but are frequently found in patients infected with hepatitis C virus, possibly indicating an underlying common origin. Likewise, mixed cryoglobulinemia often accompanies autoimmune diseases and hepatitis C infection. AIM To compare anti-nuclear antibodies and immunoglobulin content of cryoprecipitates from hepatitis C virus-positive patients in order to assess their predictive value in the onset of hepatitis C virus-driven extrahepatic disorders. METHODS Serum from 40 hepatitis C virus-positive patients and 50 controls with rheumatoid arthritis was processed for cryoglobulin detection: all subjects presented with Type III mixed cryoglobulinemia. Immunoglobulin content and immunoglobulin subclasses of cryoprecipitates were assessed by immunofixation and tested by ELISA for rheumatoid factor. Cryoprecipitates were also analysed for anti-nuclear antibodies by indirect immuno-fluorescence to identify specific patterns typical of each condition. RESULTS Anti-nuclear antibody patterns differed significantly; 26 infected subjects (65%) were IgG3 positive: of these, 25 were also anti-nuclear antibody-positive (96.1%). CONCLUSIONS IgG3 are autoreactive clones unrelated to viral recognition and possibly involved in autoimmune disorders. Altogether, these results may represent useful diagnostic device for early detection of hepatitis C virus-induced autoimmune diseases.
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281
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Min C, Higuchi T, Koyamada R, Yamaguchi N, Okada S. Pulmonary Extranodal Marginal Zone Lymphoma with Macroglobulinemia and Mixed Cryoglobulinemia Developed in a Patient with Chronic Hepatitis C. Intern Med 2015; 54:2061-4. [PMID: 26278303 DOI: 10.2169/internalmedicine.54.3968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a 65-year-old woman with a chronic hepatitis C virus infection who developed pulmonary extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissues complicated with macroglobulinemia and mixed cryoglobulinemia. She was treated with immunochemotherapy which resulted in the reduction of both the tumors and the serum immunoglobulin (Ig) M level. This case exemplifies an extensive stimulation upon immune system with derangement in the production of immunoglobulines associated with EMZL, and suggests that it is necessary to consider the possibility of B-cell lymphoma when IgM paraprotein is detected.
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Affiliation(s)
- Chisun Min
- Internal Medicine, St. Luke's International Hospital, Japan
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282
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Porres-Aguilar M, Rodriguez-Castro CE, Osvaldo P, Saifuddin F, Siddiqui T, Fan J, Mukherjee D, Pema K, Abbas A. Finger necrosis due to cryoglobulinemic vasculitis in association with membranous nephropathy. Proc AMIA Symp 2015; 28:72-4. [PMID: 25552807 PMCID: PMC4264719 DOI: 10.1080/08998280.2015.11929195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cryoglobulinemic vasculitis is a small vessel vasculitis that has been associated with chronic infections and autoimmune, lymphoproliferative, and neoplastic disorders. When no significant etiological factors are identified, it is called essential mixed cryoglobulinemia. A detailed and thorough laboratory investigation is required to exclude all possible causes of cryoglobulin formation. Although cryoglobulin testing is simple, careful temperature regulation is needed to avoid false-negative results. Consensus diagnosis should be developed and implemented for appropriate cryoglobulin detection and accurate clinical diagnosis for cryoglobulinemic vasculitis. Here we present an interesting, first-ever case report of a 54-year-old Hispanic-American woman with essential mixed cryoglobulinemia presenting with significant digital necrosis in association with membranous nephropathy.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Carlos E Rodriguez-Castro
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Padilla Osvaldo
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Fátima Saifuddin
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Tariq Siddiqui
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Jerry Fan
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Debabrata Mukherjee
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Kanchan Pema
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Aamer Abbas
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
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283
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Abstract
Pulmonary manifestations of cryoglobulinemia are uncommon and their clinical behaviour is unpredictable, ranging from mild dyspnea to life-threatening presentations. A patient with cryoglobulinemia who presented with hypoxic respiratory failure attributed to pulmonary hemorrhage is reported.
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284
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Montero N, Barrios C, Rodriguez E, Pascual J, Soler MJ. Treatment for hepatitis C virus-associated cryoglobulinaemic vasculitis. Hippokratia 2014. [DOI: 10.1002/14651858.cd011403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nuria Montero
- Hospital Universitari de Bellvitge; Department of Nephrology; Feixa LLarga s/n Barcelona Spain 08907
| | - Clara Barrios
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Eva Rodriguez
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Julio Pascual
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Maria Jose Soler
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
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285
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Harel S, Mohr M, Jahn I, Aucouturier F, Galicier L, Asli B, Malphettes M, Szalat R, Brouet JC, Lipsker D, Fermand JP. Clinico-biological characteristics and treatment of type I monoclonal cryoglobulinaemia: a study of 64 cases. Br J Haematol 2014; 168:671-8. [PMID: 25363150 DOI: 10.1111/bjh.13196] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/15/2014] [Indexed: 11/27/2022]
Abstract
This retrospective analysis was conducted in 64 patients diagnosed with type I cryoglobulinaemia (CG) followed at two French centres. Median follow-up was 6·75 years. CG was IgG in 60% and IgM in 40% of all cases and was asymptomatic in 16 patients (25%). Cold-triggered ischaemic skin manifestations were observed in 33 patients (51%). Neurological manifestations were observed in 15 patients and renal manifestations in 13. Most of the patients with necrotic purpura (14/16, P = 0·009) and renal manifestations (11/13, P = 0·057) had IgG CG. IgG CG was associated with monoclonal gammopathy of undetermined significance (MGUS), myeloma, chronic lymphocytic leukaemia and lymphoplasmocytic lymphoma in 18, 13, 5 and 2 patients, respectively. IgM CG was associated with MGUS and Waldenström macroglobulinaemia in 8 and 18 cases, respectively. One third of patients did not receive any specific treatment. Various treatments, including rituximab, were administered to 25/31 patients with IgG CG and 6/25 patients with IgM CG due to CG-related symptoms. Rituximab was ineffective in all cases associated with a predominantly plasmacytic proliferation. To conclude, type I CG has specific clinico-biological characteristics compared to type II CG. Furthermore, there are differences in terms of related manifestations between type I IgG and type I IgM CG.
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Affiliation(s)
- Stephanie Harel
- Département d'Immuno-Hématologie, Hôpital Saint-Louis, Paris, France
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286
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Nishida N, Kudo M. Clinical features of vascular disorders associated with chronic hepatitis virus infection. Dig Dis 2014; 32:786-90. [PMID: 25376297 DOI: 10.1159/000368023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hepatitis virus infections can be accompanied by extrahepatic manifestations that may be caused by the host's immune reaction to the viral infection. Vascular involvement is one of these manifestations and is occasionally associated with life-threatening conditions due to systemic organ failure. The unique profile of hepatitis-related vascular involvement is associated with infection by different types of hepatitis viruses. For example, polyarteritis nodosa is more frequently reported in patients with chronic hepatitis B than those with chronic hepatitis C. Similarly, membranous nephropathy is a notable manifestation among hepatitis B virus-positive patients. In contrast, patients infected with hepatitis C virus are at risk for cryoglobulinemia and membranoproliferative glomerulonephritis. Antiviral therapy is necessary to control these kinds of vasculitis related to hepatitis virus infections; however, immunosuppressive agents may be required to treat severe cases. New antiviral drugs for viral hepatitis could improve the prognosis of vascular and renal involvement.
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Affiliation(s)
- Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
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287
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Hurst RL, Berianu F, Ginsburg WW, Klein CJ, Englestad JK, Kennelly KD. Cryoglobulinemic vasculitis in a patient with CREST syndrome. J Clin Neurosci 2014; 21:1821-3. [DOI: 10.1016/j.jocn.2014.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 01/08/2014] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
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288
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Evaluation of the liver condition in chronic hepatitis C virus patients with and without vasculitis. THE EGYPTIAN RHEUMATOLOGIST 2014. [DOI: 10.1016/j.ejr.2014.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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289
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Affiliation(s)
- Felicia Tucci
- Institute of Cell Biology (Cancer Research), Faculty of Medicine, University of Duisburg-Essen, Virchowstr. 173, 45122, Essen, Germany
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290
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Oliveira IS, Cabral MS, Jesus LS, Paraná R, Atta AM, Sousa Atta MLB. Serum levels of immunoglobulin free light chains in patients with chronic hepatitis C presenting cryoglobulinemia. Braz J Infect Dis 2014; 18:638-42. [PMID: 25193081 PMCID: PMC9425277 DOI: 10.1016/j.bjid.2014.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 07/11/2014] [Accepted: 07/11/2014] [Indexed: 12/29/2022] Open
Abstract
Hepatitis C virus (HCV) infects B-lymphocytes, provokes cellular dysfunction and causes lymphoproliferative diseases such as cryoglobulinemia and non-Hodgkin's B-cell lymphoma. In the present study, we investigated the serum levels of kappa and lambda free light chains (FLC) of immunoglobulins and the kappa/lambda FLC ratio in Brazilian patients with chronic HCV infection and cryoglobulinemia. We also analyzed the immunochemical composition of the cryoglobulins in these patients. Twenty-eight cryoglobulinemic HCV patients composed the target group, while 37 HCV patients without cryoglobulinemia were included as controls. The median levels of kappa and lambda FLC were higher in patients with cryoglobulinemia compared to controls (p = 0.001 and p = 0.003, respectively), but the kappa/lambda FLC ratio was similar in patients with and without cryoglobulinemia (p > 0.05). The median FLC ratio was higher in HCV patients presenting with advanced fibrosis of the liver compared to HCV patients without fibrosis (p = 0.004). Kappa and lambda FLC levels were strongly correlated with the IgA, IgG and IgM levels in the patients with cryoglobulinemia. In patients without cryoglobulinemia, the kappa FLC level was only correlated with the IgG level, whereas the lambda FLC were weakly correlated with the IgA, IgG and IgM levels. An immunochemical pattern of mixed cryoglobulins (MC), predominantly IgM, IgG, IgA and kappa light chain, was verified in these immune complexes. We concluded that HCV-infected patients presenting cryoglobulinemia have vigorous polyclonal B-lymphocyte activation due to chronic HCV infection and persistent immune stimulation.
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Affiliation(s)
- Isabela S Oliveira
- Programa de Pós-Graduação em Imunologia, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Milena S Cabral
- Programa de Pós-Graduação em Imunologia, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Larissa S Jesus
- Programa de Pós-Graduação em Imunologia, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Raymundo Paraná
- Serviço de Gastroenterologia, Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Ajax M Atta
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Maria Luiza B Sousa Atta
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, BA, Brazil.
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291
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Harish V, Raymond AP, Maitz PK. Reconstruction of soft tissue necrosis secondary to cryoglobulinaemia. J Plast Reconstr Aesthet Surg 2014; 67:1151-4. [DOI: 10.1016/j.bjps.2014.03.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/24/2014] [Accepted: 03/30/2014] [Indexed: 10/25/2022]
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292
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Dustin LB, Cashman SB, Laidlaw SM. Immune control and failure in HCV infection--tipping the balance. J Leukoc Biol 2014; 96:535-48. [PMID: 25015956 DOI: 10.1189/jlb.4ri0214-126r] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Despite the development of potent antiviral drugs, HCV remains a global health problem; global eradication is a long way off. In this review, we discuss the immune response to HCV infection and particularly, the interplay between viral strategies that delay the onset of antiviral responses and host strategies that limit or even eradicate infected cells but also contribute to pathogenesis. Although HCV can disable some cellular virus-sensing machinery, IFN-stimulated antiviral genes are induced in the infected liver. Whereas epitope evolution contributes to escape from T cell-mediated immunity, chronic high antigen load may also blunt the T cell response by activating exhaustion or tolerance mechanisms. The evasive maneuvers of HCV limit sterilizing humoral immunity through rapid evolution of decoy epitopes, epitope masking, stimulation of interfering antibodies, lipid shielding, and cell-to-cell spread. Whereas the majority of HCV infections progress to chronic hepatitis with persistent viremia, at least 20% of patients spontaneously clear the infection. Most of these are protected from reinfection, suggesting that protective immunity to HCV exists and that a prophylactic vaccine may be an achievable goal. It is therefore important that we understand the correlates of protective immunity and mechanisms of viral persistence.
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Affiliation(s)
- Lynn B Dustin
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Siobhán B Cashman
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Stephen M Laidlaw
- University of Oxford, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Kennedy Institute of Rheumatology, Oxford, United Kingdom
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293
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Cryoglobulinemic glomerulonephritis in a patient with polymyositis. Am J Med 2014; 127:e7-8. [PMID: 24657335 DOI: 10.1016/j.amjmed.2014.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 02/05/2014] [Accepted: 03/03/2014] [Indexed: 11/21/2022]
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294
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Taraborelli M, Monari P, Cavazzana I, Gualdi G, Calzavara-Pinton P, Franceschini F. Severe skin involvement in type II cryoglobulinemia successfully treated with thalidomide. Joint Bone Spine 2014; 82:130-1. [PMID: 24986684 DOI: 10.1016/j.jbspin.2014.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/18/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Mara Taraborelli
- Rheumatology and Clinical Immunology Department, Spedali Civili of Brescia, piazzale Spedali Civili di Brescia 1, 25123 Brescia, Italy; University of Brescia, piazza Mercato 15, 25121 Brescia, Italy.
| | - Paola Monari
- Dermatology Department, Spedali Civili and University of Brescia, piazzale Spedali Civili di Brescia 1, 25123 Brescia, Italy
| | - Ilaria Cavazzana
- Rheumatology and Clinical Immunology Department, Spedali Civili of Brescia, piazzale Spedali Civili di Brescia 1, 25123 Brescia, Italy
| | - Giulio Gualdi
- Dermatology Department, Spedali Civili and University of Brescia, piazzale Spedali Civili di Brescia 1, 25123 Brescia, Italy
| | - Piergiacomo Calzavara-Pinton
- University of Brescia, piazza Mercato 15, 25121 Brescia, Italy; Dermatology Department, Spedali Civili and University of Brescia, piazzale Spedali Civili di Brescia 1, 25123 Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Department, Spedali Civili of Brescia, piazzale Spedali Civili di Brescia 1, 25123 Brescia, Italy
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295
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van de Donk NWCJ, Palumbo A, Johnsen HE, Engelhardt M, Gay F, Gregersen H, Hajek R, Kleber M, Ludwig H, Morgan G, Musto P, Plesner T, Sezer O, Terpos E, Waage A, Zweegman S, Einsele H, Sonneveld P, Lokhorst HM. The clinical relevance and management of monoclonal gammopathy of undetermined significance and related disorders: recommendations from the European Myeloma Network. Haematologica 2014; 99:984-96. [PMID: 24658815 PMCID: PMC4040895 DOI: 10.3324/haematol.2013.100552] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 03/14/2014] [Indexed: 12/18/2022] Open
Abstract
Monoclonal gammopathy of undetermined significance is one of the most common pre-malignant disorders. IgG and IgA monoclonal gammopathy of undetermined significance are precursor conditions of multiple myeloma; light-chain monoclonal gammopathy of undetermined significance of light-chain multiple myeloma; and IgM monoclonal gammopathy of undetermined significance of Waldenström's macroglobulinemia and other lymphoproliferative disorders. Clonal burden, as determined by bone marrow plasma cell percentage or M-protein level, as well as biological characteristics, including heavy chain isotype and light chain production, are helpful in predicting risk of progression of monoclonal gammopathy of undetermined significance to symptomatic disease. Furthermore, alterations in the bone marrow microenvironment of monoclonal gammopathy of undetermined significance patients result in an increased risk of venous and arterial thrombosis, infections, osteoporosis, and bone fractures. In addition, the small clone may occasionally be responsible for severe organ damage through the production of a monoclonal protein that has autoantibody activity or deposits in tissues. These disorders are rare and often require therapy directed at eradication of the underlying plasma cell or lymphoplasmacytic clone. In this review, we provide an overview of the clinical relevance of monoclonal gammopathy of undetermined significance. We also give general recommendations of how to diagnose and manage patients with monoclonal gammopathy of undetermined significance.
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Affiliation(s)
| | - Antonio Palumbo
- Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Hans Erik Johnsen
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Monika Engelhardt
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany
| | - Francesca Gay
- Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Henrik Gregersen
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Roman Hajek
- Department of Haemato-oncology, University Hospital Ostrava and Faculty of Medicine, Czech Republic
| | - Martina Kleber
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany
| | - Heinz Ludwig
- Department of Medicine I, Wilhelminenspital Wien, Austria
| | - Gareth Morgan
- Institute of Cancer Research, Royal Marsden Hospital, London, UK
| | - Pellegrino Musto
- Scientific Direction, Centro di Riferimento Oncologico della Basilicata, Istituto di Ricovero e Cura a Carattere Scientifico, Rionero in Vulture, Italy
| | | | - Orhan Sezer
- Department of Hematology, Memorial Hospital, Istanbul, Turkey
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Greece
| | - Anders Waage
- Department of Hematology, St. Olavs Hospital, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Hermann Einsele
- Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Henk M Lokhorst
- Department of Hematology, University Medical Center Utrecht, The Netherlands
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296
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Anis S, Abbas K, Mubarak M, Ahmed E, Bhatti S, Muzaffar R. Vasculitis with renal involvement in essential mixed cryoglobulinemia: Case report and mini-review. World J Clin Cases 2014; 2:160-166. [PMID: 24868518 PMCID: PMC4023312 DOI: 10.12998/wjcc.v2.i5.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 02/17/2014] [Accepted: 04/11/2014] [Indexed: 02/05/2023] Open
Abstract
The discovery of a strong association between hepatitis C virus (HCV) infection and mixed cryoglobulinemia (MC) has led to an increasingly rare diagnosis of idiopathic essential MC (EMC). The incidence of EMC is high in regions where there is a comparatively low HCV infection burden and low in areas of high infection prevalence, including HCV. The diagnosis of EMC requires an extensive laboratory investigation to exclude all possible causes of cryoglobulin formation. In addition, although cryoglobulin testing is simple, improper testing conditions will result in false negative results. Here, we present a 46-year-old female patient with a case of EMC with dermatological and renal manifestations, highlighting the importance of extensive investigation to reach a proper diagnosis. We review the need for appropriate laboratory testing, which is often neglected in clinical practice and which can result in false negative results. This review also emphasizes the significance of an extended testing repertoire necessary for better patient management. Despite a strong association of MC with HCV infection and other causes that lead to cryoglobulin formation, EMC remains a separate entity. Correct diagnosis requires proper temperature regulation during sample handling, as well as characterization and quantification of the cryoprecipitate. Inclusion of rheumatoid factor activity and complement levels in the cryoglobulin test-panel promotes better patient management and monitoring. Consensus guidelines should be developed and implemented for cryoglobulin detection and the diagnosis of cryoglobulinemic syndrome, which will reduce variability in inter-laboratory reporting.
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297
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Saadoun D, Cacoub P. Current and future therapeutic strategies for treating mixed cryoglobulinemia. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.883919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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298
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Yang DH, Ho LJ, Lai JH. Useful biomarkers for assessment of hepatitis C virus infection-associated autoimmune disorders. World J Gastroenterol 2014; 20:2962-2970. [PMID: 24659887 PMCID: PMC3961981 DOI: 10.3748/wjg.v20.i11.2962] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 11/10/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
During the course of chronic hepatitis C virus (HCV) infection, various extrahepatic manifestations of autoimmune disorders may occur, including arthralgia/arthritis, sicca complex, purpura, cutaneous ulcer, and thyroid dysfunction. In addition, the prevalence of circulating autoantibodies is high among patients with HCV infection. Commonly detected autoantibodies in HCV-infected patients include rheumatoid factor, antinuclear antibody, anti-SSA/anti-SSB antibody, cryoglobulin, antineutrophil cytoplasmic antibody, anti-smooth muscle antibody, anti-liver and anti-thyroid autoantibodies. These autoantibodies may be associated with underlying autoimmune disorders or liver inflammation in HCV infection. A possible reason for antibody production is overactivation and proliferation of B lymphocytes, via the interaction with the surface protein of HCV. Because immunotherapy can cause HCV flare-up or liver damage, overdiagnosis of HCV-related autoimmune symptoms as primary autoimmune disorders should be avoided. This review describes biomarkers that are useful in clinically evaluating autoimmune manifestations and disorders associated with HCV infection.
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299
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Non-Infectious Cryoglobulinemia Vasculitis (CryoVas): Update on Clinical and Therapeutic Approach. Curr Rheumatol Rep 2014; 16:420. [DOI: 10.1007/s11926-014-0420-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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300
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Caster DJ, Summersgill JT, Paueksakon P, Massung RF, Shieh WJ, McLeish KR. Mixed cryoglobulinemia and secondary membranoproliferative glomerulonephritis associated with ehrlichiosis. CEN Case Rep 2014; 3:178-182. [PMID: 28509195 DOI: 10.1007/s13730-014-0113-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 02/17/2014] [Indexed: 12/31/2022] Open
Abstract
Ehrlichiosis is a tick-borne disease with diverse clinical presentations, ranging in severity from a flu-like illness with fever and myalgias to a serious systemic disease with multisystem organ failure. Nephrotic syndrome has been reported previously in two cases of human ehrlichiosis. A kidney biopsy revealed minimal change disease in one of those patients. Herein, we present the case of a 40-year-old man with ehrlichiosis who developed nephrotic syndrome, cryoglobulinemia, and secondary membranoproliferative glomerulonephritis (MPGN). The patient originally presented with shortness of breath, diffuse myalgias, headache, and lower extremity edema. He subsequently developed acute kidney injury and underwent kidney biopsy which showed MPGN and acute tubular injury. A tick-borne disease panel was positive for IgM and IgG to Ehrlichia chaffeensis. Serum testing revealed type 3 mixed cryoglobulinemia with no evidence of hepatitis C infection. The cryoprecipitate contained IgM and IgG antibodies to E. chaffeensis. Cryoglobulinemia is frequently associated with infections, particularly hepatitis C; however, our case is the first to describe ehrlichiosis associated with cryoglobulinemia and secondary MPGN.
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Affiliation(s)
- Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, 570 South Preston Street - 102 South, Donald Baxter Research Bldg, Louisville, KY, 40202, USA.
| | - James T Summersgill
- Department of Medicine, University of Louisville School of Medicine, 570 South Preston Street - 102 South, Donald Baxter Research Bldg, Louisville, KY, 40202, USA
| | - Paisit Paueksakon
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert F Massung
- Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wun-Ju Shieh
- Infectious Diseases Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kenneth R McLeish
- Department of Medicine, University of Louisville School of Medicine, 570 South Preston Street - 102 South, Donald Baxter Research Bldg, Louisville, KY, 40202, USA.,Robley Rex VAMC, Louisville, KY, USA
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